By Cary Groner

The extent to which stretching and strengthening exercises successfully address plantar fasciitis continues to be a matter of debate among practitioners. Variables known to be associated with the condition include obesity, reduced ankle dorsiflexion, and work-related weight-bearing.

A 2008 study in Skeletal Radiology, however, added atrophy of the abductor digiti minimi muscle to the list, although it remains unclear whether the atrophy was the cause of fasciitis or its result. Similarly, a 2003 study from the University of North Carolina found that subjects with fasciitis had weaker toe flexors than did controls, but the cause and effect was unclear.

An author of that study, Michael Gross, PT, PhD, a professor of physical therapy, explained the dilemma.

“If someone already has fasciitis, and they’re guarding so that they don’t push off forcefully, that could lead to weakness of the toe flexors,” he said. “On the other hand, if they have a preexisting weakness, that could contribute to the onset of fasciitis.”

And although no controlled trials demonstrate the efficacy of exercises, Gross believes a case can be made for stretching of both the plantar fascia and the Achilles tendon for some patients.

“Heel raises will strengthen the extrinsic muscles of the foot,” he said. “The intrinsic muscles may benefit from toe grasping, which you can do by putting your foot on a weighted towel, then repeatedly curling your toes to drag the weight and the towel toward you.”

Walt Reynolds, CSCS, CPT, a personal trainer in Lansing, MI, who has written on the Web about exercises for fasciitis, still uses them occasionally with patients but has moved toward a more holistic approach.

“I work with a lot of runners, and the issues they face are largely form-related,” he said. “As a result, I now approach training on the ‘5S’ model—speed, strength, stamina, suppleness, and skill.”
Reynolds said athletes with fasciitis may experience pain in the affected foot, but the root of the problem often lies elsewhere.

“Stretches may deal with the fasciitis to a point, but they won’t address the problem that actually drives it,” he said.

When Reynolds does suggest stretching, he favors a rotational hamstring stretch, a tri-plane Achilles stretch, and a rotational plantar fascia stretch. (Detailed descriptions can be found at www.sportsinjurybulletin.com/archive/plantar-fasciitis-exercise.html.)

“When you add a rotational component, you get a more functional stretch,” Reynolds said. “Most people consider the ankle joint as working primarily in the sagittal plane, but all motion is ultimately in all three planes, and transverse-plane motion may be the most significant.”

Strengthening can simply be a matter of gait. Researchers from the German Sport University in Cologne reported at the 2005 International Society of Biomechanics conference that runners who warmed up for a few minutes with minimalist footwear increased the strength of their metatarsophalangeal joints and the cross-sectional area of their flexor hallucis, flexor digitorum, abductor hallucis, and quadratus plantae muscles.

“My theory is that we have conditioned our feet to be lazy by the overuse of arch supports,” said Irene Davis, PT, PhD, former director of the Running Research Laboratory at the University of Delaware and now with the department of physical medicine and rehabilitation at Harvard Medical School.

Although Davis recommends the usual exercises—toe grasping and heel raises (she finds the latter particularly effective if done on stairs, so that the subject begins with the heels lower than the forefoot)—she considers walking at least as important.

“One of the best exercises is to use your foot in a functional way,” she said. “If people place greater demands on their feet in a slow, progressive way, I think we can reduce the incidence of plantar fasciitis.”

Sponsored by an educational grant from OPTP